- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,041.74 / $1,517.16 / $2,080.21
| Facility | | $1,041.74 | $1,517.16 | $2,080.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.81 / $674.81 / $674.81
| Professional | | $674.81 | $674.81 | $674.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $674.81 / $674.81 / $674.81
| Facility | | $674.81 | $674.81 | $674.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.81 / $674.81 / $1,008.24
| Professional | | $674.81 | $674.81 | $1,008.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $781.40 / $1,125.28 / $5,077.04
| Facility | | $781.40 | $1,125.28 | $5,077.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.57 / $661.57 / $958.15
| Professional | | $661.57 | $661.57 | $958.15 |